Prior Hospitalization, Severe Maternal Morbidity, and Pregnancy-Associated Deaths in Massachusetts From 2002 to 2019

OBJECTIVE

To examine demographic and clinical precursors to pregnancy-associated deaths overall and when pregnancy-related deaths are excluded.

METHODS

We conducted a retrospective cohort study based on a Massachusetts population-based data system linking data from live birth and fetal death certificates to corresponding delivery hospital discharge records and a birthing individual's nonbirth hospital contacts and associated death records. Exposures included maternal demographics, severe maternal morbidity (without transfusion), hospitalizations in the 3 years before pregnancy, comorbidities during pregnancy, and opioid use. In cases of postpartum deaths, hospitalization between delivery and death was examined. The primary outcome measure was pregnancy-associated death , defined as death during pregnancy or up to 1 year postpartum.

RESULTS

There were 1,291,626 deliveries between 2002 and 2019, of which 384 were linked to pregnancy-associated deaths. Pregnancy-associated but not pregnancy-related deaths (per 100,000 deliveries) were highest for birthing people with opioid use before pregnancy (498.3), severe maternal morbidity (387.3), a comorbidity (106.3), or a prior hospitalization (88.9). In multivariable analysis, the adjusted risk ratios associated with severe maternal morbidity (9.37, 95% CI, 6.14-14.31) and opioid use (6.49, 95%, CI, 3.71-11.35) were highest. Individuals with pregnancy-associated deaths were also more likely to have been hospitalized before or during pregnancy (2.30, 95% CI, 1.62-3.26). Among postpartum deaths, more than two-thirds (69.9%) of birthing people had a hospital contact after delivery and before their death.

CONCLUSION

Severe maternal morbidity and opioid use disorder were precursors to pregnancy-associated deaths. Individuals with pregnancy-associated but not pregnancy-related deaths experienced a history of hospital contacts during and after pregnancy before death.

Development and testing of a decision aid to achieve shared decision-making for routine labor induction

BACKGROUND

This quality improvement project aimed to create a decision aid for labor induction in healthy pregnancies at or beyond 39 weeks that met the needs of pregnant people least likely to experience shared decision-making and to identify and test implementation strategies to support its use in prenatal care.

METHODS

We used quality improvement and qualitative methods to develop, test, and refine a patient decision aid. The decision aid was tested in three languages by providers across obstetrics, family medicine, and midwifery practices at a tertiary care hospital and two community health centers. Outcomes included patients' understanding of their choices, pros and cons of choices, and the decision being theirs or a shared one with their provider.

RESULTS

Patient interview data indicated that shared decision-making on labor induction was achieved. Across three Plan-Do-Study-Act cycles, we interviewed a diverse group of 24 pregnant people: 20 were people of color, 16 were publicly insured, and 15 were born outside the United States. All but one (23/24) reported feeling the decision was theirs or a shared one with their provider. The majority could name induction choices they had along with pros and cons. Interviewees described the decision-making experience as empowering and positive. Nine medical providers tested the decision aid and gave feedback. Providers stated the tool helped improve the quality of their counseling and reduce bias.

CONCLUSION

This project suggests that using an evidence-based and well-tested decision aid can help achieve shared decision-making on labor induction for a diverse group of pregnant people.

Preconception and perinatal hospitalizations as indicators of risk for severe maternal morbidity in primiparas

BACKGROUND

Severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health. A statewide longitudinally linked database was used to examine hospitalization during and before pregnancy for birthing people with severe maternal morbidity at delivery.

OBJECTIVE

This study aimed to examine the association between hospital visits during pregnancy and 1 to 5 years before pregnancy and severe maternal morbidity at delivery.

STUDY DESIGN

This study was a retrospective, population-based cohort analysis of the Massachusetts Pregnancy to Early Life Longitudinal database between January 1, 2004, and December 31, 2018. Nonbirth hospital visits, including emergency department visits, observational stays, and hospital admissions during pregnancy and 5 years before pregnancy, were identified. The diagnoses for hospitalizations were categorized. We compared medical conditions leading to antecedent, nonbirth hospital visits among primiparous birthing individuals with singleton births with and without severe maternal morbidity, excluding transfusions.

RESULTS

Of 235,398 birthing individuals, 2120 had severe maternal morbidity, a rate of 90.1 cases per 10,000 deliveries, and 233,278 did not have severe maternal morbidity. Compared with 4.3% of patients without severe maternal morbidity, 10.4% of patients with severe maternal morbidity were hospitalized during pregnancy. In multivariable analysis, there was a 31% increased risk of hospital admission during the prenatal period, a 60% increased risk of hospital admission in the year before pregnancy, and a 41% increased risk of hospital admission in 2 to 5 years before pregnancy. Compared with 9.8% of non-Hispanic White birthing people, 14.9% of non-Hispanic Black birthing people with severe maternal morbidity experienced a hospital admission during pregnancy. For those with severe maternal morbidity, prenatal hospitalization was most common for those with endocrine (3.6%) or hematologic (3.3%) conditions, with the largest differences between those with and without severe maternal morbidity for musculoskeletal (relative risk, 9.82; 95% confidence interval, 7.06-13.64) and cardiovascular (relative risk, 9.73; 95% confidence interval, 7.26-13.03) conditions.

CONCLUSION

This study found a strong association between previous nonbirth hospitalizations and the likelihood of severe maternal morbidity at delivery.

State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance

OBJECTIVE

To measure variation in delivery-related severe maternal morbidity (SMM) among individuals with Medicaid insurance by state and by race and ethnicity across and within states.

METHODS

We conducted a pooled, cross-sectional analysis of the 2016-2018 TAF (Transformed Medicaid Statistical Information System Analytic Files). We measured overall and state-level rates of SMM without blood transfusion for all individuals with Medicaid insurance with live births in 49 states and Washington, DC. We also examined SMM rates among non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance in a subgroup of 27 states (and Washington, DC). We generated unadjusted rates of composite SMM and the individual indicators of SMM that comprised the composite. Rate differences and rate ratios were calculated to compare SMM rates for non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance.

RESULTS

The overall rate of SMM without blood transfusion was 146.2 (95% CI 145.1-147.3) per 10,000 deliveries (N=4,807,143). Rates of SMM ranged nearly threefold, from 80.3 (95% CI 71.4-89.2) per 10,000 deliveries in Utah to 210.4 (95% CI 184.6-236.1) per 10,000 deliveries in Washington, DC. Non-Hispanic Black individuals with Medicaid insurance (n=629,774) experienced a higher overall rate of SMM (212.3, 95% CI 208.7-215.9) compared with non-Hispanic White individuals with Medicaid insurance (n=1,051,459); (125.3, 95% CI 123.2-127.4) per 10,000 deliveries (rate difference 87.0 [95% CI 82.8-91.2]/10,000 deliveries; rate ratio 1.7 [95% CI 1.7-1.7]). The leading individual indicator of SMM among all individuals with Medicaid insurance was eclampsia, although the leading indicators varied across states and by race and ethnicity. Many states were concordant in leading indicators among the overall, non-Hispanic Black, and non-Hispanic White populations (ie, in Oklahoma sepsis was the leading indicator for all three). Most states, however, were discordant in leading indicators across the three groups (ie, in Texas eclampsia was the leading indicator overall, pulmonary edema or acute heart failure was the leading indicator among the non-Hispanic Black population, and sepsis was the leading indicator among the non-Hispanic White population).

CONCLUSION

Interventions aimed at reducing SMM and, ultimately, mortality among individuals with Medicaid insurance may benefit from the data generated from this study, which highlights states that have the greatest burden of SMM, the differences in rates among non-Hispanic Black populations compared with non-Hispanic White populations, and the leading indicators of SMM overall, by state, and by race and ethnicity.

The Association Between Continuity Of Marketplace Coverage During Pregnancy And Receipt Of Prenatal Care

Insurance disruptions before, during, and after pregnancy are common in the United States, but little is known about the enrollment patterns of pregnant people in the Affordable Care Act Marketplaces. Data from the Pregnancy Risk Assessment Monitoring System from the period 2016-18 show that among respondents enrolled in Marketplace coverage, approximately one-third reported continuous Marketplace enrollment from preconception through the postpartum period. Compared with respondents who were continuously enrolled in Marketplace coverage from preconception through postpartum, respondents who enrolled in Marketplace plans during pregnancy had a 10.8 percent lower rate of adequate prenatal care, a 6.4 percent lower rate of timely prenatal care initiation, and a 13.2 percent lower rate of having twelve or more prenatal care visits. Policies that promote continuity of coverage during pregnancy, such as designating pregnancy as a qualifying event for a Marketplace open enrollment period, may enable pregnant people to enroll in Marketplace coverage early in their pregnancies and thus enhance access to prenatal care.

Being Known: A Grounded Theory Study of the Meaning of Quality Maternity Care to People of Color in Boston

INTRODUCTION

Experiences of people of color with maternity care are understudied but understanding them is important to improving quality and reducing racial disparities in birth outcomes in the United States. This qualitative study explored experiences with maternity care among people of color to describe the meaning of quality maternity care to the cohort and, ultimately, to inform the design of a freestanding birth center in Boston.

METHODS

Using a grounded theory design and elements of community-based participatory research, community activists developing Boston's first freestanding birth center and academics collaborated on this study. Semistructured interviews and focus groups with purposefully sampled people of color were conducted and analyzed using a constant comparative method. Interviewees described their maternity care experiences, ideas about perfect maternity care, and how a freestanding birth center might meet their needs. Open coding, axial coding, and selective coding were used to develop a local theory of what quality care means.

RESULTS

A total of 23 people of color participated in semistructured interviews and focus groups. A core phenomenon arose from the narratives: being known (ie, being seen or heard, or being treated as individuals) during maternity care was an important element of quality care. Contextual factors, including interpersonal and structural racism, power differentials between perinatal care providers and patients, and the bureaucratic nature of hospital-based maternity care, facilitated negative experiences. People of color did extra work to prevent and mitigate negative experiences, which left them feeling traumatized, regretful, or sad about maternity care. This extra work came in many forms, including cognitive work such as worrying about racism and behavioral changes such as dressing differently to get health care needs met.

DISCUSSION

Being known characterizes quality maternity care among people of color in our sample. Maternity care settings can provide personalized care that helps clients feel known without requiring them to do extra work to achieve this experience.

Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey

BACKGROUND

In many countries, cesarean section has become the most common major surgical procedure. Most nations have high cesarean birth rates, suggesting overuse. Due to the excess harm and expense associated with unneeded cesareans, many health systems are seeking approaches to safe reduction of cesarean rates. Surveys of childbearing women are a distinctive and underutilized source of data for examining factors that may contribute to cesarean reduction.

METHODS

To identify factors associated with unplanned primary cesarean birth, we carried out a secondary analysis of the Listening to Mothers in California Survey, limited to the subgroup who had not had a previous cesarean birth and did not have a planned primary cesarean (n = 1,964). Participants were identified through birth certificate sampling and contacted initially by mail and then by telephone, text message and email, as available. Sampled women could participate in English or Spanish, on any device or with a telephone interviewer. Following bivariate demographic, knowledge and attitude, and labor management analyses, we carried out multivariable analyses to adjust with covariates and identify factors associated with unplanned primary cesarean birth.

RESULTS

Whereas knowledge, attitudes, preferences and behaviors of the survey participants were not associated with having an unplanned primary cesarean birth, their experience of pressure from a health professional to have a cesarean and a series of labor management practices were strongly associated with how they gave birth. These practices included attempted induction of labor, early hospital admission, and labor augmentation. Women's reports of pressure from a health professional to have a primary cesarean were strongly related to the likelihood of cesarean birth.

CONCLUSIONS

While women largely wish to avoid unneeded childbirth interventions, their knowledge, preferences and care arrangement practices did not appear to impact their likelihood of an unplanned primary cesarean birth. By contrast, a series of labor management practices and perceived health professional pressure to have a cesarean were associated with unplanned primary cesarean birth. Improving ways to engage childbearing women and implementing changes in labor management and communication practices may be needed to reduce unwarranted cesarean birth.

Communications Between Pregnant Women and Maternity Care Clinicians

This survey study assesses patients’ self-reported communication experiences with their maternity care clinicians and examines the association of these experiences with women’s reports of feeling pressure to have interventions during delivery.

Intrapartum Care and Experiences of Women with Midwives Versus Obstetricians in the Listening to Mothers in California Survey

Introduction

Many studies based on hospital records or vital statistics have found that childbearing women experience benefits of lower rates of intervention with midwifery care versus obstetric care during labor and birth. Surveys of women's views and experiences can provide a richer analysis when comparing intrapartum care of midwives and obstetricians.

Methods

This study was a secondary analysis of data from the population‐based Listening to Mothers in California survey. The sample, which was representative of 2016 California hospital births, was drawn from birth certificate files and oversampled midwife‐attended births. Women responded to the survey in English or Spanish on any device or with a telephone interviewer. The present analysis is based on 1421 of the 2539 participants who identified a midwife or obstetrician as their attendant at a vaginal birth. A bivariate analysis of demographic, attitudinal, and intrapartum variables was conducted. A multivariable model included sociodemographic and attitudinal variables as covariates.

Results

Bivariate analyses found significant socioeconomic differences by type of intrapartum care provider, with women in California attended by midwives more likely to be well educated and privately insured than women attended by obstetricians. Women with midwife birth attendants were less likely to report experiencing various intrapartum medical interventions, less likely to experience pressure to have epidural analgesia, and more likely to report that staff encouraged the woman's decision making. Adjusted odds ratios found that women with midwives were less likely to experience medical interventions, including attempted labor induction; labor augmentation; and use of pain medications, epidural analgesia, and intravenous fluids; and less likely to report pressure to have labor induction or epidural analgesia. Women cared for by midwives were more likely to experience any nonpharmacologic pain relief measures and nitrous oxide and to agree that hospital staff encouraged their decision making.

Discussion

Using women's own reports of their care experiences and adjusting for possible differences in women's attitudes and case mix, we found that midwifery care of women who had vaginal births was associated with reduced use of medical interventions and increased women's decisional latitude during labor and birth.

Does maternity care decision-making conform to shared decision- making standards for repeat cesarean and labor induction after suspected macrosomia?

BACKGROUND

In a national United States survey, we investigated whether crucial shared decision-making standards were met for 2 common maternity care decisions.

METHODS

Secondary analysis of Listening to Mothers III. A sequence of validated questions concerning shared decision-making was adapted to 2 maternity care decisions: to induce labor or wait for spontaneous onset of labor among women who were told their baby may be "getting quite large" (N = 349); and for women with 1 or 2 prior cesareans (N = 393), the decision to have a repeat cesarean.

RESULTS

Almost half (N = 163; 47%) of women who were told their baby might be large reported engaging in a discussion concerning possible labor induction vs waiting for labor, while a large majority (N = 321; 82%) of women with a prior cesarean discussed the option of a repeat cesarean or a planned vaginal birth after cesarean (VBAC). Women who engaged in discussions received disproportionate information about having the interventions and were more likely to experience the interventions (68% induction, 87% repeat cesarean) than women who did not. After adjustment, women who reported that their provider recommended scheduling a repeat cesarean were 14 times more likely to give birth via cesarean compared with those whose providers recommended planning VBAC (AOR 14.2; 95% CI: 3.2, 63.0).

CONCLUSION

Our findings suggest that, for the decisions in question, established standards of shared decision-making are not being reliably implemented in maternity care despite opportunities to do so. Provider recommendations and the disproportionate conveyance of reasons for an intervention appear to be related to higher levels of intervention.

Assisted Reproductive Technology and Birth Defects: Effects of Subfertility and Multiple Births

BACKGROUND

Assisted reproductive technology (ART) has been associated with birth defects, but the contributions of multiple births and underlying subfertility remain unclear. We evaluated the effects of subfertility and mediation by multiple births on associations between ART and nonchromosomal birth defects.

METHODS

We identified a retrospective cohort of Massachusetts live births and stillbirths from 2004 to 2010 among ART-exposed, ART-unexposed subfertile, and fertile mothers using linked information from fertility clinics, vital records, hospital discharges, and birth defects surveillance. Log-binomial regression was used to estimate prevalence ratios and 95% confidence intervals (CIs). Mediation analyses were performed to deconstruct the ART-birth defects association into the direct effect of ART, the indirect effect of multiple births, and the effect of ART-multiples interaction.

RESULTS

Of 17,829 ART-exposed births, 355 had a birth defect, compared with 162 of 9431 births to subfertile mothers and 6183 of 445,080 births to fertile mothers. The adjusted prevalence ratio was 1.5 (95% CI, 1.3-1.6) for ART and 1.3 (95% CI, 1.1-1.5) in subfertile compared with fertile deliveries. We observed elevated rates of several birth defects with ART, including tetralogy of Fallot and hypospadias. Subfertility and multiple births affect these associations, with multiple births explaining 36% of the relative effect of ART on nonchromosomal birth defects.

CONCLUSION

Although the risk of birth defects with ART is small, a substantial portion of the relative effect is mediated through multiple births, with subfertility contributing an important role. Future research is needed to determine the impact of newer techniques, such as single embryo transfer, on these risks. Birth Defects Research 109:1144-1153, 2017. © 2017 Wiley Periodicals, Inc.

Birth Outcomes by Infertility Treatment: Analyses of the Population-Based Cohort: Massachusetts Outcomes Study of Assisted Reproductive Technologies (MOSART)

OBJECTIVE

To evaluate pregnancy and birth outcomes by type of infertility treatment received.

STUDY DESIGN

Assisted reproductive technology (ART) data on women who were both treated and gave birth in Massachusetts were linked to vital records and hospital data. Singleton and twin live births were categorized by ART treatment parameters. Risks for adverse outcomes (pregnancy-induced hypertension [PIH], gestational diabetes [GDM, primary cesarean [CS], prematurity [PTB], low birthweight [LBW], small for gestational age [SGA], large for gestational age [LGA], and birth defects [BD]) were modeled using logistic regression (adjusted odds ratios and 95% confidence intervals), adjusted for parental and treatment factors. GDM and PIH were additionally modeled as adverse outcomes.

RESULTS

Among the 8,948 pregnancies, risks were significantly higher among twins (PIH 2.58, GDM 1.30, CS 5.83, PTB 11.84, LBW 10.68, SGA 2.17, BD 2.54), donor oocytes (PIH 1.87, CS 1.43, PTB 1.43), ICSI (SGA 1.20), and the presence of > 1 fetal heartbeat at 6 weeks' gestation (2 fetal heartbeats: PTB 1.49, LBW 1.57; 3 fetal heartbeats: PTB 2.07, LBW 2.30, SGA 2.04). Thawed embryos were associated with a higher risk for PIH (1.30) but lower risks for LBW (0.79) and SGA (0.38). GDM was associated with increased risks for CS (1.22), LGA (1.40), and BD (1.50); PIH was associated with risks for CS (1.86), PTB (2.70), and LBW (1.83).

CONCLUSION

Plurality is the predominant ART treatment risk factor associated with substantial excess morbidity for both mother and infants.

Assisted Reproductive Technology and Early Intervention Program Enrollment

OBJECTIVES

We examined the prevalence of Early Intervention (EI) enrollment in Massachusetts comparing singleton children conceived via assisted reproductive technology (ART), children born to mothers with indicators of subfertility but no ART (Subfertile), and children born to mothers who had no indicators of subfertility and conceived naturally (Fertile). We assessed the natural direct effect (NDE), the natural indirect effect (NIE) through preterm birth, and the total effect of ART and subfertility on EI enrollment.

METHODS

We examined maternal and infant characteristics among singleton ART (n = 6447), Subfertile (n = 5515), and Fertile (n = 306,343) groups and characteristics associated with EI enrollment includingpreterm birth using χ(2) statistics (α = 0.05). We estimated the NDE and NIE of the ART-EI enrollment relationship by fitting a model for enrollment, conditional on ART, preterm and the ART-preterm delivery interaction, and covariates. Similar analyses were conducted by using Subfertile as the exposure.

RESULTS

The NDE indicated that the odds of EI enrollment were 27% higher among the ART group (odds ratioNDE = 1.27; 95% confidence interval (CI): 1.19 ̶ 1.36) and 20% higher among the Subfertilegroup (odds ratioNDE = 1.20; 95% CI: 1.12 ̶ 1.29) compared with the Fertile group, even if the rate of preterm birth is held constant.

CONCLUSIONS

Singleton children conceived through ART and children of subfertile mothers both have elevated risks of EI enrollment. These findings have implications for clinical providers as they counsel women about child health outcomes associated with ART or subfertility.

Severe Maternal Morbidity and the Use of Assisted Reproductive Technology in Massachusetts

OBJECTIVE

To assess whether risk of severe maternal morbidity at delivery differed for women who conceived using assisted reproductive technology (ART), those with indicators of subfertility but no ART ("subfertile"), and those who had neither ART nor subfertility ("fertile").

METHODS

This retrospective cohort study was part of the larger Massachusetts Outcomes Study of Assisted Reproductive Technology. To construct the Massachusetts Outcomes Study of Assisted Reproductive Technology database and identify ART deliveries, we linked ART treatment records to birth certificates and maternal and infant hospitalization records occurring in Massachusetts between 2004 and 2010. An algorithm of International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes identified severe maternal morbidity. We used logistic generalized estimating equations to estimate odds of severe maternal morbidity associated with fertility status, adjusting for maternal demographic and health factors and gestational age, stratifying on plurality and method of delivery.

RESULTS

The prevalence of severe maternal morbidity among this population (n=458,918) was 1.16%. The overall, crude prevalences of severe maternal morbidity among fertile, subfertile, and ART deliveries were 1.09%, 1.44%, and 3.14%, respectively. The most common indicator of severe maternal morbidity was blood transfusion. In multivariable analyses, among singletons, ART was associated with increased odds of severe maternal morbidity compared with both fertile (vaginal: adjusted odds ratio [OR] 2.27, 95% confidence interval [CI] 1.78-2.88; cesarean: adjusted OR 1.67, 95% CI 1.40-1.98, respectively) and subfertile (vaginal: adjusted OR 1.97, 95% CI 1.30-3.00; cesarean: adjusted OR 1.75, 95% CI 1.30-2.35, respectively) deliveries. Among twins, only cesarean ART deliveries had significantly greater severe maternal morbidity compared with cesarean fertile deliveries (adjusted OR 1.48, 95% CI 1.14-1.93).

CONCLUSION

Women who conceive through ART may have elevated risk of severe maternal morbidity at delivery, largely indicated by blood transfusion, even when compared with a subfertile population. Further research should elucidate mechanisms underlying this risk.

Is the wrong question being asked in infertility research?

A persistent finding is that assisted reproductive technology (ART) is associated with compromised birth outcomes, including higher risks for prematurity, low birthweight, and congenital malformations, even among singletons. Over the past decade, our research group, the Massachusetts Outcome Study of Assisted Reproductive Technology (MOSART), has evaluated pregnancy and birth outcomes among three groups of women, those women treated with ART, those with indicators of subfertility but without ART treatment, and fertile women. We have also explored the influence of infertility-related diagnoses on outcomes for women and infants. Over the course of our research, we have changed our perspective from an original focus on ART treatment parameters as the primary cause of excess morbidity to one centered instead on the underlying infertility-related diagnoses. This paper summarizes the research findings from our group that support this change in focus for infertility-based research from a primary emphasis on ART treatment to greater attention to the contribution of preexisting pathology underlying the infertility and suggests directions for future analyses.

Birth Outcomes by Infertility Diagnosis Analyses of the Massachusetts Outcomes Study of Assisted Reproductive Technologies (MOSART)

OBJECTIVE

To evaluate assisted reproductive technology (ART) pregnancy outcomes by infertility diagnosis.

STUDY DESIGN

ART data on women who were treated and gave birth in Massachusetts were linked to vital records and hospital utilization data. Live births were categorized by 8 mutually exclusive ART diagnoses. Risks of prematurity, low birthweight (LBW), small-for-gestational age (SGA), large-for-gestational age (LGA), pregnancy hypertension, gestational diabetes, prenatal hospitalizations, and primary cesarean delivery were modeled using logistic regression, adjusted for parental characteristics, treatment parameters, and plurality (adjusted odds ratios [AORs] and 95% confidence intervals); the reference group were pregnancies with the diagnosis of malefactor.

RESULTS

Among the 7,354 singleton and twin pregnancies, there were nonsignificant differences in the risks for LBW, SGA, or LGA. Significantly increased risks included gestational diabetes (ovulation disorders, AOR 1.80, 1.35-2.41), prematurity (ovulation disorders, AOR 1.36, 1.08-1.71; other factors, AOR 1.33, 1.05-1.67), prenatal hospital admissions (endometriosis, tubal and other factors, ovulation disorders, and uterine factors, AORs ranging from 1.66-2.68), and primary cesarean section (uterine factors, AOR 1.96, 1.15-3.36).

CONCLUSION

Although the infant outcomes of LBW, SGA, and LGA were generally similar across diagnosis groups, specific diagnoses had greater risks for prematurity, gestational diabetes, prenatal hospital utilization, and primary cesarean delivery. (J Reprod Med 2015;

Racial and Ethnic Differences in the Likelihood of Vaginal Birth After Cesarean Delivery

BACKGROUND

A major contributor to the increase in cesarean deliveries over recent decades is the decline in vaginal births after cesarean (VBAC). Racial and ethnic disparities in other perinatal outcomes are widely recognized, but few studies have been directed toward racial/ethnic differences in VBAC rates.

METHODS

We used the population-based Massachusetts Pregnancy to Early Life (PELL) database to investigate racial/ethnic differences in rates of VBAC for Massachusetts residents with one prior cesarean from 1998 to 2008.

RESULTS

The overall VBAC rate was 17.3 percent. After adjusting for demographic, behavioral, and medical risk factors, non-Hispanic Asian mothers had a greater likelihood of VBAC than non-Hispanic white mothers (adjusted risk ratio 1.31 [95% CI 1.23-1.39]). No other racial/ethnic group was significantly different from non-Hispanic whites in adjusted analyses. The likelihood of VBAC also decreased with increasing maternal age.

DISCUSSION

Non-Hispanic Asian women are significantly more likely to have VBAC than non-Hispanic white women. Efforts to reduce cesarean delivery rates in the United States should address these disparities. Future research should investigate factors underlying these differences to ensure that all women have access to appropriate maternity care services.

Adverse pregnancy outcomes after in vitro fertilization: effect of number of embryos transferred and plurality at conception

OBJECTIVE

To evaluate risks for adverse pregnancy outcomes by number of embryos transferred (ET) and fetal heartbeats (FHB) in assisted reproductive technology-conceived singleton live births.

DESIGN

Longitudinal cohort using cycles reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System between 2004 and 2008 among women who were treated and gave birth in Massachusetts.

SETTING

Not applicable.

PATIENT(S)

Assisted reproductive technology data on 6,073 births between 2004 and 2008 were linked to vital records and hospital data. Likelihood of ET ≥3 vs. 1-2, FHB >1 vs. 1, and risks of preterm birth (PTB, <37 weeks' gestation), low birth weight (LBW, <2,500 g), and small-for-gestational-age birth weight (SGA, <10th percentile) with FHB >1 were modeled with binary logistic regression using a backward-stepping algorithm, and presented as adjusted odds ratios (95% confidence intervals).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

ET ≥3, FHB >1, PTB, LBW, and SGA.

RESULT(S)

Higher ET was significantly more likely with older maternal age, intracytoplasmic sperm injection, assisted hatching, cleavage-stage embryos, and thawed embryos. The likelihood of FHB >1 with ≥3 ET vs. 1-2 ET was 2.04 (1.68-2.48). Risks of PTB and LBW with FHB >1 were 1.63 (1.27-2.09) and 1.81 (1.36-2.39), respectively; the risk of SGA was not significant. Nulliparity was associated with higher risks of PTB (1.34 [1.12-1.59]), LBW (1.48 [1.20-1.83]), and SGA (2.17 [1.69-2.78]).

CONCLUSION(S)

Number of embryos transferred was strongly associated with FHBs, with twice the risk of FHB >1 with ≥3 ET vs. 1-2 ET. Increasing FHBs were associated with significantly greater risks for PTB and LBW outcomes.

Major Survey Findings of Listening to Mothers(SM) III: Pregnancy and Birth: Report of the Third National U.S. Survey of Women's Childbearing Experiences

To understand the experiences and views of childbearing women in the United States and trends over time, Childbirth Connection carried out the third national Listening to Mothers survey among 2,400 women who gave birth in U.S. hospitals to a single baby from mid-2011 to mid-2012 and could participate in English. Harris Interactive conducted the survey using a validated methodology that includes data weighting to ensure that results closely reflect the target population. Results of the initial survey describe experiences from before pregnancy through the early postpartum period, and were reported in Listening to Mothers III: Pregnancy and Birth. A follow-up survey directed to the same participants explored postpartum experiences, attitudes about maternity care, and some additional pregnancy and birth items.

Identifying women with indicators of subfertility in a statewide population database: operationalizing the missing link in assisted reproductive technology research

OBJECTIVE

To identify a group of deliveries to mothers with indicators of subfertility (SUBFERTILITY).

DESIGN

Longitudinal cohort study.

SETTING

Hospital.

PATIENT(S)

A total of 334,152 deliveries to Massachusetts mothers in a Massachusetts hospital between July 1, 2004, and December 31, 2008.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Subfertility was defined by an indication on a current or past birth certificate or hospital utilization data of infertility or assisted reproductive technology (ART) cycle before index delivery and no indication of ART use with index delivery.

RESULT(S)

Initially, 12,367 deliveries met the inclusion criteria for SUBFERTILITY (8,019 from birth certificates, 2,777 from hospital data, 1,571 from prior ART treatment). Removing deliveries from more than one data source resulted in 10,764 unique deliveries. Removing deliveries resulting from ART treatments left 6,238 deliveries in the SUBFERTILITY category. Demographic analysis indicated that deliveries in SUBFERTILITY were more similar to those in the ART population than to those in the fertile population.

CONCLUSION(S)

We have demonstrated the feasibility of using existing population-based linked public health data sets to identify SUBFERTILITY deliveries, and we have used ART data to distinguish ART and SUBFERTILITY births. The SUBFERTILITY category can serve as a comparison group of subfertile patients for studies of ART delivery and longitudinal health outcomes.

Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences: Conducted January-February 2006 for Childbirth Connection by Harris Interactive(R) in partnership with Lamaze International

With permission from Childbirth Connection, the concise version of the Listening to Mothers II "Survey Methodology" is reprinted here. Harris Interactive(R) conducted Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences on behalf of Childbirth Connection. The survey consisted of 1,373 online interviews and 200 telephone interviews with women who had given birth in U.S. hospitals in 2005, with weighting of data to reflect the target population. Interviews were conducted from January 20 through February 21, 2006. The methods used to conduct the survey and analyze the data collected are described.

Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences: Conducted January-February 2006 for Childbirth Connection by Harris Interactive(R) in partnership with Lamaze International

With permission from Childbirth Connection, the "Executive Summary" for the Listening to Mothers II survey is reprinted, here. The landmark Listening to Mothers I report, published in 2002, described the first national U.S. survey of women's maternity experiences. It offered an unprecedented opportunity to understand attitudes, feelings, knowledge, use of obstetric practices, outcomes, and other dimensions of the maternity experience. Listening to Mothers II, a national survey of U.S. women who gave birth in 2005 that was published in 2006, continues to break new ground. Although continuing to document many core items measured in the first survey, the second survey includes much new content, exploring earlier topics in greater depth, as well as some new and timely topics.

Posttraumatic stress disorder in new mothers: results from a two-stage U.S. national survey

BACKGROUND

Prevalence rates of women in community samples who screened positive for meeting the DSM-IV criteria for posttraumatic stress disorder after childbirth range from 1.7 to 9 percent. A positive screen indicates a high likelihood of this postpartum anxiety disorder. The objective of this analysis was to examine the results that focus on the posttraumatic stress disorder data obtained from a two-stage United States national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey (LTM II/PP).

METHODS

In the LTM II study, 1,373 women completed the survey online, and 200 mothers were interviewed by telephone. The same mothers were recontacted and asked to complete a second questionnaire 6 months later and of those, 859 women completed the online survey and 44 a telephone interview. Data obtained from three instruments are reported in this article: Posttraumatic Stress Disorder Symptom Scale-Self Report (PSS-SR), Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire-2 (PHQ-2).

RESULTS

Nine percent of the sample screened positive for meeting the diagnostic criteria of posttraumatic stress disorder after childbirth as determined by responses on the PSS-SR. A total of 18 percent of women scored above the cutoff score on the PSS-SR, which indicated that they were experiencing elevated levels of posttraumatic stress symptoms. The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health-promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well-being since birth. A stepwise multiple regression revealed that two predictor variables significantly explained 55 percent of the variance in posttraumatic stress symptom scores: depressive symptom scores on the PHQ-2 and total number of physical symptoms women were experiencing at the time they completed the LTM II/PP survey.

CONCLUSION

In this two-stage national survey the high percentage of mothers who screened positive for meeting all the DSM-IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic.

The practice of nurse-midwifery in the era of managed care: reports from the field

OBJECTIVE

The purpose of this paper is to describe the reports of certified nurse-midwives (CNMs) about how changes in the financing and organization of health care in the late 1990s influenced their ability to serve vulnerable populations and provide a woman-centered, prevention-oriented midwifery model of care.

METHODS

A 13-page survey was mailed to all CNMs ever certified by the American College of Nurse-Midwives (N = 6365) in July 1998. The survey included closed- and open-ended questions. A total of 2405 CNMs responded: of these, 2089 were in clinical practice during the study period (1997-98) and 82% of the 2089 (N = 1704) wrote responses to the open-ended questions and were included in the qualitative database. We present responses to the closed-ended questions about seven domains of practice and elaborate on three major themes identified through content analysis of the qualitative data.

RESULTS

The majority (57%) reported that the changes in the larger health care environment had influenced their practices during 1997-98. The effects most frequently reported were 1) increased client loads (31%); 2) altered style of practice (30%): 3) inability to serve the same populations; (20%); 4) decreased client loads (20%); and 5) increased administrative duties (17%). Three major themes were identified and elaborated upon in the qualitative data: 1) challenges to the style of midwifery practice related to the managed care environment; 2) the loss of socially and economically at-risk women from CNMs' client base; and 3) barriers to high quality and comprehensive services for women.

CONCLUSIONS

During the late 1990s as managed care was expanding and health systems were merging, a significant number of CNMs in the field described threats to their ability to sustain economically viable practices and a style of care consistent with the woman-centered, prevention-oriented midwifery model.

Serving women in need: nurse-midwifery practice in the United States

OBJECTIVE

Nurse-midwifery practices in the United States were examined to study the relationship between certified nurse-midwives' (CNMs) demographic, work setting, and practice characteristics in terms of clientele, practice size, and practice type. Factors that might influence the ability of CNMs to serve populations at risk for poor outcomes were given particular attention.

METHODOLOGY

A total of 2,405 responses to a 1998 mailed survey of 6,365 nurse-midwives ever-certified by the American College of Nurse-Midwives were analyzed.

RESULTS

Study results indicated that CNMs continue to serve a population who are, based on a social risk profile, disproportionately at risk for poor pregnancy outcomes, including women who are uninsured (16%), immigrant (27%), adolescent (29%), and women of color (50%). It was also found that clientele varied according to practice settings: CNMs working in non-hospital, nonprofit settings served a clientele that was 65% nonwhite, 44% immigrant, 40% adolescent, and 29% uninsured; these CNMs received 61% of their client payments from Medicaid. CNMs working in private offices or for managed care organizations were less likely to serve women with these characteristics.

CONCLUSION

Study results, taken in conjunction with research that documents the safety of nurse-midwifery practice, reinforce policy recommendations that support expanded access to nurse-midwifery services. Findings also indicate a need for further research in the areas of CNM workload and productivity in managed care settings and the association between CNM race and ethnicity and the race and ethnicity of their clients.

A comparison of visits and practices of nurse-midwives and obstetrician-gynecologists in ambulatory care settings

With more than 5 million patient visits annually, certified nurse-midwives (CNMs) substantially contribute to women's health care in the United States. The objective of this study was to describe ambulatory visits and practices of CNMs, and compare them with those of obstetrician-gynecologists (OB/GYNs). Sources of population-based data used to compare characteristics of provider visits were three national surveys of CNMs and two National Ambulatory Medical Care Surveys of physicians. When a subset of 4,305 visits to CNMs in 1991 and 1992 were compared to 5,473 visits to OB/GYNs in similar office-based ambulatory care settings in 1989 and 1990, it was found that a larger proportion of CNM visits were made by women who were publicly insured and below age 25. The majority of visits to CNMs were for maternity care; the majority of visits to OB/GYNs were for gynecologic and/or family planning concerns. Face-to-face visit time was longer for CNMs, and involved more client education or counseling. This population-based comparison suggests that CNMs and OB/GYNs provide ambulatory care for women with diverse demographic characteristics and differing clinical service needs. Enhancing collaborative practice could improve health care access for women, which would be especially beneficial for those who are underserved and vulnerable.

A time to be born

OBJECTIVES

This study used a large, population-based data set (n = 619,455) to establish reference standards of the timing of spontaneous vaginal births.

METHODS

Low-risk births in Massachusetts from 1989 to 1995 were studied. This group comprised 242,276 births that met the following criteria: singleton, vertex, vaginal births with a birthweight of between 2500 and 4000 g; gestation between 37 and 42 weeks; a 5-minute Apgar score greater than 6, and no induction or stimulation.

RESULTS

Low-risk births displayed a mild circadian pattern, with a peak between 11:00 AM and 1:00 PM and a trough between 11:00 PM and 1:00 AM. Subgroup analysis showed no clear differences except for parity.

CONCLUSIONS

Reference standards should be developed and used as comparative norms for hospital and practice-based perinatal studies of diurnal patterns of birthing.

Characteristics of nurse-midwife patients and visits, 1991

OBJECTIVES

This study describes the patient populations served by and visits made to certified nurse-midwives (CNMs) in the United States.

METHODS

Prospective data on 16,729 visits were collected from 369 CNMs randomly selected from a 1991 population survey. Population estimates were derived from a multistage survey design with probability sampling.

RESULTS

We estimated that approximately 5.4 million visits were made to nearly 3000 CNMs nationwide in 1991. Most visits involved maternity care, although fully 20% were for care outside the maternity cycle. Patients considered vulnerable to poor access or outcomes made 7 of every 10 visits.

CONCLUSIONS

Nurse-midwives substantially contribute to the health care of women nationwide, especially for vulnerable populations.

State regulation, payment policies, and nurse-midwife services

State regulatory and reimbursement policies continue to exert a strong influence on health workforce policy. Surveys conducted in 1991 and 1995 for the purpose of examining the impact of state regulation on the supply and practice of certified nurse-midwives (CNMs) showed that the single best predictor of the distribution and practice activities of CNMs was the degree to which state policies facilitated or restricted CNM practice.

Population-based needs assessment. Bringing public health to midwifery practice

Midwives are accustomed to individualizing their care of women on the basis of an assessment of each client's health status. By expanding their focus of care to encompass treatment of a population group, midwives and other providers can adopt a public health perspective through use of a community needs assessment. The first steps in diagnosing and treating the health problems of a group require the same rigorous and systematic examination of health indicators as does treatment of an individual. This article outlines the needs assessment process, identifies basic sources of information, and describes ways in which results can be presented.

Home birth in the United States, 1989-1992. A longitudinal descriptive report of national birth certificate data

This study was conducted to profile home birth in the United States from 1989 to 1992 using two birth certificate data sources from the Natality Branch of the National Center for Health Statistics (NCHS). Analysis included published and unpublished descriptive tables about all U.S. home births from 1989 to 1992, and a subset of the 82,210 U.S. home births from 1989 to 1991 that were drawn from NCHS national birth certificate data tapes. Results indicated that less than one-third of reported home births were attended by nurse-midwives or physicians. Distinct regional patterns in the frequency of home births were observed, with higher concentrations in the southwestern and western states. When compared with the average childbearing woman in the United States, mothers who gave birth at home were more likely to be older, have fewer years of education, be married, and be white; they were also more likely to be of higher parity and to receive less prenatal care. Home birth mothers were less likely than average to smoke or drink alcohol prenatally, to have a prenatal medical risk condition or an obstetric complication, or to receive certain prenatal tests. The outcomes of newborns born at home compared favorably to the national average during the same period. Several findings varied considerably by race or ethnicity of the mother.

Midwifery care and medical complications: the role of risk screening

This study analyzed the 147,293 births attended by midwives in the United States in 1989. It used the revised and expanded standard national certificate of a live birth, which for the first time systematically records prenatal medical risk, intrapartum complications, obstetric procedures, and birth outcomes. It builds on earlier findings of positive outcomes for midwife-attended births to examine the prenatal medical risk profile of mothers served by midwives, the performance of obstetric procedures by midwives in different birth settings, more specific measures of outcomes, and possible explanations for these findings. Although midwives attending births in birth centers and homes generally serve mothers who are at much less than average medical risk, and in cases of intrapartum complications risk screening appears to occur, nurse-midwife-attended births in hospitals involve mothers whose risk profiles compare with, and in some cases are worse than, the national average. Nonetheless, the outcomes of these births are better than the national average. Mothers attended by midwives in birth centers and homes also have a different pattern of prenatal care, which begins later and includes fewer visits, but gives more apparent attention to self-care, and results in less smoking and alcohol use and greater weight gain.

A cross-national analysis of midwifery politics: six lessons for midwives

Research based on interviews and analysis of documentary sources on the politics of midwifery in Canada, Denmark, the Netherlands, the UK and the US, suggests six political lessons for midwives and the organisations that represent them. The lessons are: general health reforms represent both an opportunity and a threat to midwives' status, and midwives must learn to communicate in ways policy makers understand; research matters; coalition building is essential; the media cares (a little); it is much easier to defend the status quo than create new policy; it is essential to clarify who is to be considered a midwife. A constant grass roots awareness of and involvement in a country's political and policy making process is seen as a necessity if midwives are to prosper as a profession.

The trials of Hanna Porn: the campaign to abolish midwifery in Massachusetts

The case of Hanna Porn affords an opportunity to examine how the laws that led to the abolition of midwifery in Massachusetts evolved and were applied to the midwife whose case set the state legal precedent. Mrs Porn served primarily a Finnish-Swedish clientele of wives of laborers. The outcomes of the births she attended appear to have been positive, and she maintained a neonatal mortality rate of less than half that of local physicians. She also repeatedly defied court orders to stop practicing. Her case exemplifies the efforts that occurred nationally to abolish midwifery in the United States.

Where babies are born and who attends their births: findings from the revised 1989 United States Standard Certificate of Live Birth

OBJECTIVE

To examine the results of changes in the birth certificate with regard to characteristics of the mothers and the birth weights of their infants. The United States Standard Certificate of Live Birth was revised in 1989 to include specific designations for the place of births out of hospital and the presence of a nurse-midwife or other midwife at the birth.

METHODS

All results are based on data from the Natality, Marriage and Divorce Statistics Branch of the National Center for Health Statistics, Centers for Disease Control. In all cases reported here, the data represent at least 91% of all United States births in 1989.

RESULTS

Different patterns of birth attendance emerged in different settings. In residential births, other midwives and "others" attended 66% of all births, whereas in freestanding birth centers, physicians and certified nurse-midwives attended 75.1% of all births. The characteristics of the mothers differed substantially according to who attended their births in these settings. Substantial interstate variations in place and attendant were also documented.

CONCLUSION

The positive outcomes achieved in certain settings indicate a need for further research into the factors that influence birth outcomes.

The transformation of American midwifery: 1975 to 1988

BACKGROUND

The use of midwives is a natural solution to the problem of improving access to skilled perinatal services while lowering costs. The number of midwife-attended births has grown from 0.9% of all births in 1975 to 3.4% of all births in 1988. The purpose of the study was to determine how mothers served by midwives and the settings in which they are served have changed in that period.

METHODS

The analysis is based on birth certificate data from 1975 to 1988 from the Natality, Marriage and Divorce Statistics Branch of the National Center for Health Statistics, Centers for Disease Control.

RESULTS

Almost all of the growth (93.2%) in midwife-attended births from 1975 to 1988 was in hospitals; 87.3% of all births attended by midwives occurred in hospitals. Pronounced differences exist between mothers served by midwives in and outside of hospitals, and there are strong regional patterns in midwife attendance at birth.

CONCLUSIONS

Given the positive outcomes associated with midwifery practice, further research into the content of midwifery care is recommended.

Out-of-hospital births, U.S., 1978: birth weight and Apgar scores as measures of outcome

An examination of 1978 natality data for the United States disclosed that low birth weight was less common among 30,819 infants born out of hospital than among 3,294,101 infants born in hospital in that year. When controls were applied for birth attendant, infants' race, and mothers' education, age, nativity, and parity, the data revealed that white, well-educated women between 25 and 39 years of age, who were having their second babies and were attended by midwives out of hospital, were at least risk of bearing low birth weight infants. The incidence rate of low birth weight babies was lower for midwife-attended births in every category examined. For college-educated white women, for example, the incidence rate was 2.0 percent among those attended by midwives, 4.6 percent among those giving birth in hospital, and 3.6 percent among those whose out-of-hospital deliveries were attended by physicians. Apgar scores for babies born both in and out of hospital were also studied but, because of inconsistent reporting, were given less attention. Excellent (9-10) Apgar scores were more common among babies born out of hospital than among those born in hospital (63 percent compared with 49 percent), particularly for out-of-hospital births attended by physicians. At least with respect to birth weight and Apgar scores, the claim that out-of-hospital births are inherently more dangerous than hospital births receives no support from these data. The findings also suggest the need for further refinement of vital statistics categories to permit the analysis of distinctions between births attended by certified nurse-midwives and those attended by lay midwives, as well as differences between births at home and those in alternative birth centers.